Prevalence Of True Resistant Hypertension Research Articles

Prevalence of true resistant hypertension in those referred for uncontrolled hypertension in Malaysia: A comparison using different definitions.

Resistant hypertension is a well-recognised clinical challenge. However, the definition and epidemiology of true resistant hypertension (RH) are less understood, especially in Asia. This cross-sectional study examined the prevalence of RH referred from primary care clinics based on various guidelines. RH was defined as blood pressure (BP) being above the threshold using ambulatory blood pressure monitoring despite adequate lifestyle measures and optimal treatment with ≥3 medications at maximally tolerated doses. Between one in four (n = 94, 24.0% using Malaysian guidelines) and up to two-thirds (n = 249, 63.7% using 2018 American guidelines) of adults referred for uncontrolled hypertension met the criteria of true RH. Of those with RH, a further one-quarter (n = 26, 26.6%) were deemed to have refractory hypertension (elevated BP despite treatment with at least 5 antihypertensive medications). Adults with RH were generally younger, more likely to be male, had a higher BMI and were more likely to have gout, CKD, and angina compared to those with controlled hypertension. The prevalence of RH amongst Asian adults with poor hypertension control is high. A concerted effort is needed to reduce the high burden of RH, especially among this population.

PREVALENCE OF APPARENT-TREATMENT RESISTANT HYPERTENSION IN PERITONEAL DIALYSIS PATIENTS ASSESSED WITH THE USE OF 24-HOUR AMBULATORY BLOOD PRESSURE MONITORING

Objective: The prevalence of apparent-treatment resistant hypertension (aTRH) among patients with predialysis chronic kidney disease is 2–3 times higher than in the general population. The aim of the present study was to investigate the prevalence of aTRH in end-stage kidney disease (ESKD) patients undergoing peritoneal dialysis (PD). Design and method: A total of 140 ESKD patients treated with PD in 4 centers of Northern Greece underwent 24-hour ambulatory blood pressure monitoring with the oscillometric device Mobil-O-Graph (IEM, Stolberg, Germany). aTRH was defined as 24-hour ambulatory blood pressure (BP) equal or higher than 130/80 mmHg, despite the use of at least 3 antihypertensive medications of different categories or controlled hypertension in patients treated with at least 4 antihypertensives. Loop diuretics that are commonly prescribed in PD patients for long-term preservation of residual kidney function are generally ineffective in lowering BP and were not considered as a separate antihypertensive drug category in our analysis. To explore the association of volume overload with the severity of hypertension, the body composition of study participants was analyzed via bioimpendence spectroscopy (BCM, Fresenius Medical Care, Germany). Results: Of the 140 PD patients enrolled in the study, 42 (30%) had aTRH, 45 (32.1%) had uncontrolled hypertension under treatment with < 3 BP-lowering medications and the remaining 53 patients (37.9%) were either normotensives or had controlled hypertension with < 3 antihypertensives. The prevalence of aTRH among drug-treated hypertensives was 32.5%. Overhydration > 2.5L with the use of bioimpendence spectroscopy was detected in 38.1% of patients with aTRH, in 15.6% of patients with uncontrolled hypertension and in 18.9% of normotensives or patients with controlled hypertension (P< 0.05). Conclusions: The present study showed that aTRH affects approximately 30% of ESKD patients undergoing PD. However, the prevalence of true-resistant hypertension in this high-risk population is probably lower, since 38.1% of patients with aTRH had subclinical volume overload detected with the method of bioimpendence spectroscopy.

Application of omics in hypertension and resistant hypertension.

Hypertension is a major modifiable risk factor that affects the global health burden. Despite the availability of multiple antihypertensive drugs, blood pressure is often not optimally controlled. The prevalence of true resistant hypertension in treated hypertensive patients is ~2-20%, and these patients are at higher risk for adverse events and poor clinical outcomes. Therefore, an in-depth dissection of the pathophysiological mechanisms of hypertension and resistant hypertension is needed to identify more effective targets for regulating blood pressure. Omics technologies, such as genomics, transcriptomics, proteomics, metabolomics, and microbiomics, can accurately present the characteristics of organisms at varying molecular levels. Integrative omics can further reveal the network of interactions between molecular levels and provide a complete dynamic view of the organism. In this review, we describe the applications, progress, and challenges of omics technologies in hypertension. Specifically, we discuss the application of omics in resistant hypertension. We believe that omics approaches will produce a better understanding of the pathogenesis of hypertension and resistant hypertension and improve diagnostic and therapeutic strategies, thus increasing rates of blood pressure control and reducing the public health burden of hypertension.

The Burden of Resistant Hypertension Across the World.

Resistant hypertension (R-HTN) is related to worse cardiovascular, renal outcomes, and death compared to non R-HTN. We aimed to review the burden of R-HTN across the world, focusing on its prevalence, associated factors and outcomes, and the impact of treatment. R-HTN prevalence among hypertensive individuals varies around 10-20%, depending on the population and definition applied. R-HTN consistently relates to older age, chronic kidney disease, obesity, and obstructive sleep apnea - which are increasing in prevalence with global population aging. As such, R-HTN prevalence is also expected to rise. Infrequent use of ambulatory blood pressure monitoring to identify at higher risk individuals and poor adherence to treatment are still barriers in the approach of R-HTN. Available evidence suggests that 10-20% of patients with hypertension have R-HTN. However, the prevalence of true R-HTN using contemporaneous standardized definitions is still unknown. Novel strategies to address clinicians, patients and health system barriers to treatment inertia and adherence are fundamental to reduce the burden of R-HTN.

Resistant Hypertension: Where are We Now and Where Do We Go from Here?

Resistant hypertension is an important subtype of hypertension that leads to an increased risk of cerebrovascular, cardiovascular, and kidney disease. The revised guidelines from the American College of Cardiology and American Heart Association now define resistant hypertension as blood pressure that remains above goal despite use of three maximally titrated anti-hypertensive medications including a diuretic or as a hypertensive patient who requires 4 or more agents for adequate BP control. These agents typically include a calcium-channel blocker, a renin-angiotensin system inhibitor, and a diuretic at maximal or maximally tolerated doses. As recognition of resistant hypertension increases, it is important to distinguish pseudo-resistant or apparent hypertension from true resistant hypertension. Etiologies of apparent resistant hypertension include measurement error and medication non-adherence. The prevalence of true resistant hypertension is likely much lower than reported in the literature when accounting for patients with apparent resistant hypertension. Evaluation of patients with true resistant hypertension includes screening for causes of secondary hypertension and interfering medications. Successful management of resistant hypertension includes lifestyle modification and optimization of medical therapy, often including the use of mineralocorticoid receptor antagonists. Looking ahead at developments in hypertension management, a slew of new device-based therapies are under active development. Of these, renal denervation is the closest to routine clinical application. Further study is needed before these devices can be recommended in the routine treatment of resistant hypertension.

Abstract P175: Resistance Hypertension and Achievement of Target Blood Pressure

Aim: To evaluate the characteristics of patients with resistant arterial hypertension (RAH) and assessed the prevalence of true resistant hypertension in patients who takes 3 and more antihypertensive agents. Materials and methods: The study included 1146 patients with AH who received 3 or more antihypertensive drugs. The average level of systolic (SBP) / diastolic (DBP) blood pressure was (174,60 ± 0,64) / (100,50 ± 0,38) mm Hg. Results: Our data showed that in patients who received 3 or more drugs in (31%) goal blood pressure was not reached, it means true resistant hypertension. 3 drugs were received (51.4%) patients, 4 drugs - (37.1%), 5 drugs - (9.1%), and 6 drugs - (2.4%) of patients. ACE inhibitors were prescribed in 65.5%, calcium antagonists - in 69.9%, diuretics - in 91.8%. Beta-blockers - 75.5%, AT II blockers - 33.5%, aldosterone receptor blockers - 12.8%. Fixed combinations - 71.9%. Patients who did not achieve targeted SBP (31%) had higher cortisol (155.0 ± 44.0 vs 35.9 ± 20.8 ng/l), left ventricular mass index (147.5 ± 3.46 vs 135.3 ± 1.74 g/m 2 ), obesity (42.9% vs 37.5%), kidney abnormality (2.7% vs 0.8%), nephropathy (1.3% vs 0.2%), and heart failure (16.9% vs 8.5%). Patients taking 4 and more drugs had higher glucose levels - (6.20 ± 0.09) mmol/l vs (5.90 ± 0.14) mmol/l (p <0.05) and the lower renin (31.10 ± 5.91) ng/l vs (218.30 ± 15.73) ng/l (p <0.05). Conclusion: patients who received 3 or more antihypertensive drugs in 31% had true resistant hypertension. They had higher blood cortisol level, left ventricular mass index, obesity, kidney abnormality and more often heart failure.

Resistant Hypertension: Diagnosis and Management.

Resistant hypertension is defined as high blood pressure requiring 3 or more medications for adequate control or controlled blood pressure requiring 4 or more medications. Considering the growing prevalence of hypertension and the strong link with cardiovascular disease, it is vital to understand the causes and treatment of resistant hypertension. This review article starts with an overview of the prevalence and little-known pathophysiology of resistant hypertension. Afterward, we discuss the evaluation and management of suspected secondary resistant hypertension in 2 broad categories: pseudoresistant hypertension and true resistant hypertension. Strategies for the identification and management of pseudoresistant hypertension are addressed. In addition, causes of true resistant hypertension, such as obstructive sleep apnea, primary aldosteronism, and renal artery stenosis, are examined along with their respective treatments. Finally, treatment of resistant hypertension is reviewed including pharmacologic treatments and novel procedural interventions for resistant hypertension. Overall, the review hopes to provide practitioners with a cohesive approach for the diagnosis and treatment of resistant hypertension.

PP.10.09] PREVALENCE OF TRUE RESISTANT HYPERTENSION IN UNCOMPLICATED HYPERTENSIVES WITH APPARENT TREATMENT-RESISTANT HYPERTENSION IN LONGITUDINAL REAL-LIFE STUDY

Objective: Our aim was to compare target office (<140/90mmHg) and home (<135/85 mmHg) blood pressure (BP) attainment after 6-month (6 M) of standardized algorithmic treatment in uncomplicated hypertensives (UH), with clinical BP previously uncontrolled on 3 or more antihypertensive medications, ie with apparent treatment-resistant hypertension (aTRH). Design and method: 54 Kiev city cardiologists recruited in PERFECT-BP prospective observational study (ISRCTN75706523) 407 treated but uncontrolled UH (BP < 200/120 mmHg), aged 59,3 ± 8,9 years, 42,3% male. At visit 1 patients (pts) were prescribed or switched to a fixed-dose combination (FDC) of perindopril/amlodipine (doses at discretion of MDs), which was followed by FDC uptitration, and, if needed, by consecutive addition of indapamide SR, spironolactone, and moxonidine or doxazosin. Office BP measurements were performed with standardized automatic device Microlife BPW200 with universal cuff. Home BP measurements were performed with validated oscillometric device Microlife BP3AG1 with individually selected cuff, twice pd for 7 consecutive days before each visit at day 7, M1, 2, 3, 6. After 6 M treatment pts compliance was assessed by X. Gererd questionnaire. Results: Baseline therapy of 122(30%) pts included 3 or more drugs (aTRH group) with optimal treatment regimens in 28(23%) of them. By 6 M office systolic BP in aTRH pts decreased from 166,1 ± 14,6 to 132,8 ± 9,4 mmHg, diastolic BP – from 97,7 ± 10 to 79,3 ± 7,3mmHg. At 6 M 63% of pts with aTRH attained target office BP by triple therapy, 11,1% – by 4 or more drugs, with masked hypertension in 21,3% of them. Target office and home BP despite of 3 or more drugs, prescribed in optimal doses, were not attained in 10,2% of aTRH pts with high or moderate adherence. Low adherence was the reason for lack of office BP control in 4,6% of pts, physician[Combining Acute Accent]s inertia (only 2 drugs were prescribed) – in 7,4%. White coat hypertension was identified in 3,7% of aTRH pts. Conclusions: Target office BP after 6 M of standardized algorithmic treatment based on FDC in real life setting was attained in 74,1% of UN with baseline aTRH, with 10,2% prevalence of true resistant hypertension.

0164 : Contribution of ambulatory blood pressure in the therapeutic management of hypertension

Hypertension is a major cardiovascular risk factor associated with significant morbidity and mortality. Because of the risk of white coat effect which increases the blood pressure in the office, the ambulatory blood pressure (ABPM) is a good tool to assess the blood pressure profile of the patient, adapting its treatment and establish its prognosis. assess the impact of ABPM in the therapeutic management of hypertensive patients diagnosed and treated. Retrospective study spread over 1 year (May 2014-May 2015), analyzing 202 patients of the ABPM register of cardiology department (UH Ibn Rochd of Casablanca) for therapeutic evaluation. The average age of the study population was 59 years (26-97 years). 59% of patients in our study were women, with a sex ratio at 0.69. Age and obesity are the most common risk factors (43%), followed by diabetes found in 27% and tobacco in 13%. The analysis of 202 ABPM performed in treated hypertensive patients allowed to retain the following: - The effect of “white coat” was found in 56% of patients who should avoid unnecessary therapeutic escalation. - 51% of patients experienced a nocturnal hypertension. - About half of patients do not lower their blood pressure at night despite treatment. 10% have increased contrary to their nocturnal pressure. - 4% of patients were considered extreme dippers. - Finally, about 9% of patients in our population that are considered hypertensive patients resistant to treatment, the ABPM was diagnosed a white coat effect in half of these patients (5% prevalence of true resistant hypertension). The MAPA is an invaluable tool for the management of hypertensive patients under treatment. This work encourages us to reflect on the definition of perfect control of blood pressure which, in our view, should not only normalize daytime blood pressure but also restore the circadian rhythm. The author hereby declares no conflict of interest

P3-26: Prevalence of true resistant hypertension among uncontrolled hypertensive patients referred to a tertiary health care center

Objectifs La frequence de l'hypertension arterielle resistante (HTAr) varie selon les etudes. Ceci est lie, en partie, a l'heterogeneite des definitions utilisees, et des populations incluses. Les patients avec HTAr sont a tres haut risque d'evenements cardiovasculaires. L'objectif de l'etude etait d'estimer la prevalence de l'HTAr chez des hypertendus traites non controles, adresses dans un centre specialise dans la prise en charge de l'HTA. Methodes Etude prospective observationnelle descriptive, ayant inclus tous les patients hypertendus de plus de 18 ans, traites depuis au moins 12 mois et adresses pour HTA non controlee a l'unite d'hypertension du CHU de Tiziouzou entre janvier 2013 et avril 2015. L'HTAr etait definie par une PA de consultation superieure ou egale a 140/90 mmHg, malgre une tritherapie incluant un diuretique, un bloqueur du systeme renine angiotensine et un inhibiteur calcique a doses optimales, pendant au moins 4 semaines. Pour estimer la prevalence de l'HTAr avec une precision de 2 % et une confiance de 95 %, il fallait inclure au minimum 2 185 sujets. Resultats Nous avons inclus 2 367 patients, d'âge moyen de 61.1 ± 11,2 ans, dont 64.2 % d'hommes. 35.6 % (n = 843) avaient un traitement non optimal (moins de 3 medicaments, doses suboptimales, combinaisons inappropriees) ; 15.4 % (n = 364) etaient des mauvais observants du traitement (auto-questionnaire de 6 questions) et 8.5 % (n = 202) avaient un effet blouse blanche (automesure ou MAPA). 958 patients presentaient les criteres retenus pour definir l'HTAr, soit une prevalence de 40.5 % (IC95 % : 38.6 % – 42.4 %). Parmi ceux-ci, 3.8 % (n = 36) avaient une consommation excessive d'alcool et/ou de medicaments pouvant favoriser la resistance et 29.3 % (n = 281) une consommation de sel (Nacl) superieure a 15 g/24 heures (natriurese des 24 heures). Les causes secondaires d'HTA identifiees etaient l'hyperaldosteronisme primaire (n = 204 ; 21.3 %), le syndrome d'apnees obstructives du sommeil (n = 151 ; 15.8 %), la stenose significative de l'artere renale (n = 83 ; 8.7 %) et autres causes (n = 30 ; 3.1 %). Finalement, seuls 173 patients, representant 7.3 % (IC95 % : 6.3 % – 8.3 %) de la population initiale incluse, presentaient une HTAr « vraie » et etaient eligibles a une intensification du traitement antihypertenseur (4 molecules ou plus) ; leurs caracteristiques cliniques etaient : diabete (27.2 %) ; tabagisme (39.3 %) ; BMI moyen a 30.6 ± 4.7 kg/m 2 ; DFGe median a 63,2 ml/mn/1.73m 2 (IQR : 73.6 – 34.3) et antecedents d'evenements cardiovasculaires majeurs (21.4 %). Conclusion Moins d'un patient sur 10 adresse dans notre centre pour HTA non controlee presentait une HTAr « vraie » necessitant une intensification du traitement antihypertenseur.

Prevalence and clinical characteristics of renal transplant patients with true resistant hypertension.

Arterial hypertension is a prevalent complication that occurs in 75-90% of kidney-transplant recipients. Data about resistant arterial hypertension are scarce. The aim of this multicenter, cross-sectional, and observational study was to assess the prevalence and the clinical features of true resistant hypertension among renal-transplant patients. Eligible patients included hypertensive cadaveric kidney-transplant recipients aged below 70 years, with functioning kidney for at least 1 year, and with an estimated glomerular filtration rate at least 30 ml/min per 1.73 m and serum creatinine below 2.5 mg/dl. Recorded data included demographic characteristics, office blood pressure, and ambulatory blood pressure monitoring and laboratory investigations. A total of 868 patients (mean age 53.2 ± 11.6 years) were included. Mean systolic and diastolic office blood pressure was 140.2 ± 18 and 80.4 ± 10 mmHg, respectively. Mean 24-h ambulatory SBP and DBP was 131.5 ± 14 and 77.4 ± 8.7 mmHg and the prevalence of true resistant hypertension was 18.9%. Those with resistant hypertension were older and men, with a worse cardiovascular risk profile and history of cardiovascular disease. Apart from this, these patients had worse graft function and treatment with steroids. The present study provides evidence about the prevalence of true resistant hypertension in renal-transplant patients. It also shows the very high cardiovascular risk of true resistant hypertension and the elevated association of this condition with renal failure, organ damage, and history of cardiovascular events.

Apparent and true resistant hypertension: definition, prevalence and outcomes

Resistant hypertension, defined as blood pressure (BP) remaining above goal despite the use of > or =3 antihypertensive medications at maximally tolerated doses (one ideally being a diuretic) or BP that requires > or =4 agents to achieve control, has received more attention with increased efforts to improve BP control rates and the emergence of device-based therapies for hypertension. This classically defined resistant group consists of patients with true resistant hypertension, controlled resistant hypertension and pseudo-resistant hypertension. In studies where pseudo-resistant hypertension cannot be excluded (for example, 24-h ambulatory BP not obtained), the term apparent resistant hypertension has been used to identify 'apparent' lack of control on > or =3 medications. Large, well-designed studies have recently reported the prevalence of resistant hypertension. Pooling prevalence data from these studies and others within North America and Europe with a combined sample size of >600,000 hypertensive participants, the prevalence of resistant hypertension is 14.8% of treated hypertensive patients and 12.5% of all hypertensives. However, the prevalence of true resistant hypertension, defined as uncontrolled both by office and 24-h ambulatory BP monitoring with confirmed medication adherence, may be more meaningful in terms of identifying risk and estimating benefit from newer therapies like renal denervation. Rates of cardiovascular events and mortality follow mean 24-h ambulatory BPs in patients with resistant hypertension, and true resistant hypertension represents the highest risk. The prevalence of true resistant hypertension has not been directly measured in large trials; however, combined data from smaller studies suggest that true resistant hypertension is present in half of the patients with resistant hypertension who are uncontrolled in the office. Our pooled analysis shows prevalence rates of 10.1% and 7.9% for uncontrolled resistant hypertension among individuals treated for hypertension and all hypertensive individuals, respectively.

Transcatheter therapies for resistant hypertension: Clinical review.

Resistant hypertension (RHTN) is a commonly encountered clinical problem and its management remains a challenging task for healthcare providers. The prevalence of true RHTN has been difficult to assess due to pseudoresistance and secondary hypertension. Atherosclerotic renal artery stenosis (RAS) has been associated as a secondary cause of RHTN. Initial studies had shown that angioplasty and stenting for RAS were a promising therapeutic option when added to optimal medical management. However, recent randomized controlled trials in larger populations have failed to show any such benefit. Sympathetic autonomic nervous system dysfunction is commonly noted in individuals with resistant hypertension. Surgical sympathectomy was the treatment of choice for malignant hypertension and it significantly improved mortality. However, post-surgical complications and the advent of antihypertensive drugs made this approach less desirable and it was eventually abandoned. Increasing prevalence of RHTN in recent decades has led to the emergence of minimally invasive interventions such as transcatheter renal denervation for better control of blood pressure. It is a minimally invasive procedure which uses radiofrequency energy for selective ablation of renal sympathetic nerves located in the adventitia of the renal artery. It is a quick procedure and has a short recovery time. Early studies in small population showed significant reduction in blood pressure. The most recent Symplicity HTN-3 study, which is the largest randomized control trial and the only one to use a sham procedure in controls, failed to show significant BP reduction at 6 mo.

Prevalência de hipertensão resistente em adultos não idosos: estudo prospectivo em contexto ambulatorial

In face of variable definitions and sampling criteria, the real prevalence of resistant hypertension in a clinical setting is unknown. We investigated the prevalence of true resistant hypertension in an outpatient hypertension clinic. True resistant hypertension was diagnosed when white coat phenomenon, lack of compliance and secondary hypertension were excluded in patients with blood pressure ≥ 140/90 mmHg in two consecutive visits, despite to be using three blood pressure-lowering agents, including a diuretic. In the total, 606 patients, with 35 to 65 years of age, mostly women, with BP of 156.8 ± 23.8 mmHg by 91.9 ± 15.6 mmHg and a BMI of 29.7 ± 5.9 Kg/m² were sequentially evaluated. One hundred and six patients using three BP drugs had uncontrolled blood pressure (17.5% of the whole sample) in the first visit. Eighty-six patients (81% of the patients with uncontrolled BP in the first evaluation) returned for the confirmatory evaluation. Twenty-five had controlled BP, 21 had evidence of low adherence to treatment, 13 had white coat phenomenon and 9 had secondary hypertension, leaving only 18 patients (20.9% of those uncontrolled in the confirmatory visit and 3% of the whole sample) with true resistant hypertension. Considering patients with secondary hypertension as cases of resistant hypertension, the prevalence of resistant hypertension increased to 4.5%. The frequency of patients with true resistant hypertension in non-elderly patients is low in a clinical setting, and is not substantially increased with the inclusion of patients with secondary hypertension.

Response to Evaluating the True Prevalence of Resistant Hypertension

The National Health and Nutrition Examination Survey is a set of studies that were not specifically designed to determine the prevalence of true resistant hypertension in the US population. Accordingly, the estimates of the prevalence of resistant hypertension determined using the National Health and Nutrition Examination Survey data should be interpreted in the context of known, and previously stated, limitations.1 The white-coat effect, partial medication nonadherence, and inadequate medication dosage cannot be excluded, and, therefore, some individuals would have been falsely classified as having resistant hypertension. Using the …

Evaluating the True Prevalence of Resistant Hypertension

To the Editor: We are grateful to de la Sierra et al1 and Persell2 for their worthy effort to provide significant information about the prevalence of true resistant hypertension.1,2 These important articles fill a long-lasting gap in the hypertension field, yet we believe that several concerns interfere in the evaluation of this phenomenon in addition to those discussed in the accompanying editorial comments3,4 and should be cautiously acknowledged. Regarding the article by de la Sierra et al,1 the true prevalence of resistant hypertension might have been underestimated. First, 1757 subjects taking ≥4 antihypertensive drugs, irrespective of office blood pressure, who were, by definition resistant hypertensives, were excluded from the study for reasons not adequately …

High Prevalence of Secondary Hypertension and Insulin Resistance in Patients with Refractory Hypertension

Objective: To determine causes of treatment resistance in patients with refractory hypertension, and to estimate the prevalence of true resistant hypertension. Methods: We studied 50 consecutive patients referred with refractory hypertension after exclusion of hypokalemia and stenosis of the renal artery. Ambulatory blood pressure monitoring was performed in all patients to detect white-coat effect. The patients were hospitalized, antihypertensive drugs were withdrawn and a screening for secondary hypertension was performed. In addition, these patients, and a control group of essential hypertensives controlled with three antihypertensive drugs, underwent a OGTT with 75 g of glucose. Results: Primary normokaliemic hyperaldosteronism was diagnosed in seven patients. Two patients had a pheochromocytoma and six had white-coat effect. The 35 remaining patients with true resistant hypertension shown significant differences in serum insulin and HOMA IR when compared with the control group. Conclusions: These findings show that among normokaliemic treatment-resistant hypertension, the presence of hyperaldosteronism and pheochromocitoma is quite high. Moreover, treatment resistance in hypertensive patients appears to be associated with insulin resistance.